Fascinating interview. Wes Streeting may have been quicker off the mark than many Cabinet colleagues, but from an NHS perspective his approach felt too slow. The 10 year plan did not appear for a year, for example. If Streeting and advisers had prepared better, it would have taken half this time.
On welfare reforms and NEETs, surely this requires serious work across Whitehall and history is not encouraging on this. Alan concedes that Labour’s missions have not got traction and these above all demand cross Whitehall leadership with visible and sustained leadership by the PM. We’ve not seen that sadly
I think you’re right although I would be more damming of Streeting and his advisers. I don’t think they prepared at all, and in my experience of using the NHS since, is making things worse. A few examples:
- Certainly where I live in London last year was bad but this year was much worse with the introduction of corridor care.
- I saw a specialist this time last year for a serious acute condition and he wanted to see me again. It turns out I was dumped off his list and when I rang was told I had to wait over a year to see him. As I am a hospice patient, I have friends in the same position. I suspect waiting lists are going down because of manipulation.
- I was urgently referred to a thoracic surgeon 5 times by my local hospital but they got no response. I am having to see the surgeon privately to ask for an NHS appt. A similar thing happened before Christmas.
If Streeting was working in any other sector, he would have been sacked but politicians like him and Milburn are allowed to fail before moving into the private sector to enrich themselves.
Mr Milburn also claims that “with something like the [health department] 10 year plan, that ended up being written by a small group of people, me included, with the mainstream machine largely exempted from that process, which is just an odd thing to do”.
Mr Milburn’s political philosophy is outlined in the section where he says, “What the government’s got to be is an agent for change. You do it through strategic clarity and narrative creation. The biggest job of leadership today in any setting, corporate or politics, is a job of explanation. What is going on in the world. Why is it happening? What are the choices before us? You create narratives and one of the things that worries me most is when people say: the answer to all of this doesn’t lie in any of that stuff, strategy or narrative but in delivery.”
Apart from some wafty rhetoric about a triple shift that is clearly not happening and some ‘tough’ rhetoric about failure not being tolerated, it is extremely hard to discern what the current Milburn-Streeting era’s NHS strategic clarity and narrative creation is meant to be.
Absolutely spot on. I think it shows that Milburn has used this interview to create a narrative that simply isn’t true. He has spent most of his career in the private sector and it sounds like the sort of nonsense that people would spout in business meetings.
He is either completely detached from reality or just, I suspect, trying to promote a positive spin out of failure. Maybe he should go and talk to the very sick people on trolleys in corridors at my local hospital and hospitals around the country.
I am going to make an "old codger" point - when I was 14 I was legally permitted to be employed part time - I delivered newspapers, worked in a bakery and in a shop and in the summer holidays on farms. I was paid admittedly not very much (I wasn't having to make a living) but it felt much more than it was (and I got tips at Christmas - more from the little houses than the big ones; another lesson). I learned to turn up. I learned that personal engagement and performance was expected of me and I acquired skills. At the end of a period of work I could see what I had achieved. We were introduced to adulthood with adults who were also working. The same with nearly all my friends. It was normal. And I am convinced that it paid off in terms of commitment to school work as well
I would say that the current government *does* think in argument. Keir Starmer's a lawyer by trade, arguing is absolutely his bread and butter.
What is missing is the actual politics. Again, very lawyerly. A lawyer can make the case for any proposition without stopping to question whether he personally believes it.
Sometimes a lawyer is useful. It was certainly useful when Starmer was picking apart the innumerable scandals of the last Conservative government. But when running a country is not enough to be good at arguing; you first need to know what you are arguing *for.*
There needs to be a part played by employers. Covid plus NHS failure has left people who could do some work, frozen out of the labour market. More part time flexible opportunities are required. This is where the attack on PIP was misguided as it is an in work benefit. And the reduction of Motability to 10K miles is a disaster for parents doing the school run and travelling for work (eg a library manager in a rural area I know).
Second - no one really looks at whether some of the NEETS are actually doing quite well outside the system. Cash in hand, drug dealing etc. There’s a thriving off the books economy in my bit of West London and Surrey.
Blimey, if Streeting is the example of “hitting the ground running” then the mess we’re in makes considerably more sense. Also, has anyone told Alan that his ten year plan for the NHS really wasn’t very good. Maybe getting more civil servants involved might have stopped the massive structural reorganisation of the NHS we just blundered into
Excellent arguments about why Labour profiled themselves as political wet paper towels. I somehow understand that, but when they noticed that this weak attitude wasn’t at all appreciated among their own supporters (aka voters), they should have sat down, formulate a strategy to deal with this and go for change with some gusto. Most of all they should have talked about what they’re after and use the feedback to reconsider their stance on e.g. Brexit much earlier. Start discussions about what was necessary versus what was possible to limit the increasingly visible economical damage.
The Socialists want to raise taxes & give everything away for FREE. This badly damages the MORAL base on which society stands. On the other hand, the neo-Nazis of the extreme right are hardly a MORAL improvement.
Society cannot be held hostage by a continuous tit for tat gunfight between the extremes of left & right. I hold that the two-party system has passed its USE BY date.
At this time, we need to be developing a well-crafted CENTRIST party; one that can govern even-handedly. Then turn to these two extremes to declare A POX ON BOTH YOUR HOUSES.
Ken, I have a book in the Dutch language in which, during a fraught discussion between a sergeant and a private, the argument about socialists giving away everything is dealt with in the almost exact wording that you use. Sorry mate, it’s nonsense. The ones giving away millions to their buddies are the likes of Boris Johnson or Nigel Farage.
"The big difference is that the risk aversion is 500% higher. I’ve thought a lot about why that might be, and there are many factors, but I think one of the principal reasons is towards the end of the Conservative era the senior civil service came to believe that its job was to save the country from the government. Maybe that was a good thing, given it was chaos, but that’s left a legacy. So I see more and hear more ‘not sure about that, oh dear that will be quite difficult’.
I see this here in the US, at all levels, and not just in government. It might almost be the theme of the times. Those that have jobs - private or public - are desperate to keep them, and the rest live in a gig economy that's far from secure. Pushing for real change is a risky and uncertain business. Keeping one's head down therefore makes sense, while the alternative offers little payoff.
This was an interesting choice for an interview, Sam, and I was intrigued to read it. Whilst I would love to be a dispassionate observer on the areas covered by Alan Milburn, in this interview, I can’t be. I caught an infection in a London Hospital in 2007 (I was one of many who did at that time because infection control was a major problem) and I still have that infection now because it spread to my bones - I was lost to follow up (long story but largely as a result of New Labour’s reforms).
I take issue with Milburn almost immediately because he says ‘Oh, they’re not as good as we were’ that’s not true. He’s right in one sense, he was not very good and neither were several of his successors. He inherited an NHS in a much better, but still struggling, state than it is now but the decisions made by the last Labour govt are partly responsible for the mess it’s in now. PFI saddled the NHS with enormous debts and it took far too long for the last Labour govt to get hospital acquired infections under control. Moreover, the scandal of mixed wards continued well into the 2000’s and it was the coalition govt that finally claimed it had ended them.
I think most people agree that the Thatcherite status quo in this country has failed because creating monopolies run by private businesses who cream off huge sums of public money is doomed. The big failure of this current administration is that they promised change but have instead brought back people Milburn, and Mandelson, who didn’t do a good job the first time, to advise on continuing the status quo - but maybe in a slightly different way.
To touch on Milburn’s other area, he’s looking at welfare but that is another mess created by the last Labour govt. I think it was James Parnell who thought private firms could employ speech therapists and suchlike to decided on a sick person’s capability to work. Ian Duncan Smith just took this and made it far worse whilst continuing to enrich outsource companies. What unique skill does Milburn possess that will improve welfare in this country? He’s spent most of his career working for private healthcare companies.
I have nothing against the private sector as I worked in the private sector for my working life. However, when they carry out actions previously carried out by the state and do a much worse job but at huge expense I do object strongly. How can Streeting and Milburn think that throwing huge amounts of money at shareholder and directors is going to fix the NHS?
Thank you Sam and Alan. It does me good to hear a lot of common sense from a fellow Geordie. Ah, the "vision" thing and leadership developing a narrative that the people will follow! It would be nice to feel that the polycritical political context would allow even the present mediocrities running the place were capable of rising to the occasion. Alan, you seem to have greater faith in Wes Streeting's capacity to envision and embody such an approach. It would be interesting to hear more about him and what he has under his belt in the light of the current chaotic pre-electoral "Starmer is walking dead" crisis.
Interesting to read about the need for argument and coherence in vision, strategy and delivery. About 20 years ago I became involved in the programme to close many of the Remploy factories and transform the organisation into one that found work for those with disabilities in mainstream employers. Agree or disagree with the policy, there was a clear line of sight between the programme and a speech that Blair had made years earlier on Rights and Responsibilities, the overarching aim of which was to raise the percentage of people in employment. The equally controversial policy to move single parents from income support to Job Seekers Allowance was part of the same vision.
Alan’s ideas of system change are not ones you agree with Sam as you have stated this is likely not the best place to start as so many obstacles. I can see this having been a civil servant.
Alan is praying that the leadership capacity and more important capability will materialise to do this. I cannot see it , but i too pray it will emerge.
It could come through institutionalising a system wide system of incentives for encouraging improvement rather than checking vs lists as current inspectorates do.
The Audit Commission, before it became a best value inspectorate of checkers did this with some success.
Would really appreciate if you would release the actual audio of the interview as a podcast. Hearing it via AI-generated voice isn’t the same. ChinaTalk does this in reverse, I’m sure you can too!! Thanks for sharing.
Thanks. I can't in this instance because it was recorded in a noisy cafe so the audio is unlistenable! But it's a good nudge for future interviews. Part of the challenges is that I cut them down a lot to make them readable so the audio would be different from the published transcript so need to think about how that would work.
For instance, ChinaTalk records the podcast first and then generates the transcript. Both available on Substack. It’s possible via RSS feed ID to make audio available to subscribers via Apple Podcasts. Or via the hideous Substack podcast player 🤣🤣
Yeah - I think the difference is they do there's as podcasts and the transcripts are a secondary resource whereas I do them to be written up. I've toyed with the idea of doing proper podcasts as part of the substack but I'm so attached to writing that I don't enjoy it nearly as much!
Fascinating interview. Wes Streeting may have been quicker off the mark than many Cabinet colleagues, but from an NHS perspective his approach felt too slow. The 10 year plan did not appear for a year, for example. If Streeting and advisers had prepared better, it would have taken half this time.
On welfare reforms and NEETs, surely this requires serious work across Whitehall and history is not encouraging on this. Alan concedes that Labour’s missions have not got traction and these above all demand cross Whitehall leadership with visible and sustained leadership by the PM. We’ve not seen that sadly
I think you’re right although I would be more damming of Streeting and his advisers. I don’t think they prepared at all, and in my experience of using the NHS since, is making things worse. A few examples:
- Certainly where I live in London last year was bad but this year was much worse with the introduction of corridor care.
- I saw a specialist this time last year for a serious acute condition and he wanted to see me again. It turns out I was dumped off his list and when I rang was told I had to wait over a year to see him. As I am a hospice patient, I have friends in the same position. I suspect waiting lists are going down because of manipulation.
- I was urgently referred to a thoracic surgeon 5 times by my local hospital but they got no response. I am having to see the surgeon privately to ask for an NHS appt. A similar thing happened before Christmas.
If Streeting was working in any other sector, he would have been sacked but politicians like him and Milburn are allowed to fail before moving into the private sector to enrich themselves.
Some remarkable assertions about current health reform, which don’t tally up with events.
Mr Milburn claims that there was “thinking behind the scenes. Wes Streeting did that and could hit the ground running as a result”.
The notion that Mr Streeting had done the work and so hit the ground running is not widely held. It is not evident in delivery, where RTT waiting list reductions (Labour’s one quantified 2024 manifesto commitment on health) are happening, but desperately slowly: far too slowly to hit the pledge for 2029 https://www.hsj.co.uk/quality-and-performance/year-end-elective-sprint-off-to-a-slow-start/7041526.article.
It is not evident in policy, where Mr Streeting’s major change in abolishing NHS England https://www.hsj.co.uk/integrated-care/nhse-to-be-formally-abolished/7038852.article is something that he said he would not do ten weeks beforehand https://www.hsj.co.uk/acute-care/exclusive-govt-abandons-commitment-to-hit-cancer-mental-health-and-aande-targets/7038590.article.
It is not evident in strategy, where the NHS Ten-Year Plan is essentially a wish list, without any means of delivery https://www.hsj.co.uk/policy-and-regulation/exclusive-10-year-plan-published-without-delivery-chapter/7039607.article.
Mr Milburn also claims that “with something like the [health department] 10 year plan, that ended up being written by a small group of people, me included, with the mainstream machine largely exempted from that process, which is just an odd thing to do”.
This is an odd statement: there was a very large consultation exercise https://www.gov.uk/government/publications/enabling-working-group-reports-10-year-health-plan-for-england. If the 10 Year Plan was then written by a small group who largely ignored the output of that consultation, it would explain a lot about its many deficiencies.
Mr Milburn’s political philosophy is outlined in the section where he says, “What the government’s got to be is an agent for change. You do it through strategic clarity and narrative creation. The biggest job of leadership today in any setting, corporate or politics, is a job of explanation. What is going on in the world. Why is it happening? What are the choices before us? You create narratives and one of the things that worries me most is when people say: the answer to all of this doesn’t lie in any of that stuff, strategy or narrative but in delivery.”
The New Labour health reforms of the 2000s had a coherent narrative, and were largely based in ‘New Public Management’-style incentives for more activity; helped by earned autonomy for providers; spiced up at the margins by competition https://www.kingsfund.org.uk/insight-and-analysis/reports/understanding-new-labours-market-reforms-english-nhs; but largely lubricated by a huge amount of extra money. The NHS’s annual budget went from £49 billion in 2000 news.bbc.co.uk/1/hi/in_depth/uk/2000/budget2000/684419.stm to £131 billion in 2010 https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/nhs-budget-nutshell.
Apart from some wafty rhetoric about a triple shift that is clearly not happening and some ‘tough’ rhetoric about failure not being tolerated, it is extremely hard to discern what the current Milburn-Streeting era’s NHS strategic clarity and narrative creation is meant to be.
Absolutely spot on. I think it shows that Milburn has used this interview to create a narrative that simply isn’t true. He has spent most of his career in the private sector and it sounds like the sort of nonsense that people would spout in business meetings.
He is either completely detached from reality or just, I suspect, trying to promote a positive spin out of failure. Maybe he should go and talk to the very sick people on trolleys in corridors at my local hospital and hospitals around the country.
I am going to make an "old codger" point - when I was 14 I was legally permitted to be employed part time - I delivered newspapers, worked in a bakery and in a shop and in the summer holidays on farms. I was paid admittedly not very much (I wasn't having to make a living) but it felt much more than it was (and I got tips at Christmas - more from the little houses than the big ones; another lesson). I learned to turn up. I learned that personal engagement and performance was expected of me and I acquired skills. At the end of a period of work I could see what I had achieved. We were introduced to adulthood with adults who were also working. The same with nearly all my friends. It was normal. And I am convinced that it paid off in terms of commitment to school work as well
Agree a full 100%!
I would say that the current government *does* think in argument. Keir Starmer's a lawyer by trade, arguing is absolutely his bread and butter.
What is missing is the actual politics. Again, very lawyerly. A lawyer can make the case for any proposition without stopping to question whether he personally believes it.
Sometimes a lawyer is useful. It was certainly useful when Starmer was picking apart the innumerable scandals of the last Conservative government. But when running a country is not enough to be good at arguing; you first need to know what you are arguing *for.*
Couple of things:
There needs to be a part played by employers. Covid plus NHS failure has left people who could do some work, frozen out of the labour market. More part time flexible opportunities are required. This is where the attack on PIP was misguided as it is an in work benefit. And the reduction of Motability to 10K miles is a disaster for parents doing the school run and travelling for work (eg a library manager in a rural area I know).
Second - no one really looks at whether some of the NEETS are actually doing quite well outside the system. Cash in hand, drug dealing etc. There’s a thriving off the books economy in my bit of West London and Surrey.
Blimey, if Streeting is the example of “hitting the ground running” then the mess we’re in makes considerably more sense. Also, has anyone told Alan that his ten year plan for the NHS really wasn’t very good. Maybe getting more civil servants involved might have stopped the massive structural reorganisation of the NHS we just blundered into
Excellent arguments about why Labour profiled themselves as political wet paper towels. I somehow understand that, but when they noticed that this weak attitude wasn’t at all appreciated among their own supporters (aka voters), they should have sat down, formulate a strategy to deal with this and go for change with some gusto. Most of all they should have talked about what they’re after and use the feedback to reconsider their stance on e.g. Brexit much earlier. Start discussions about what was necessary versus what was possible to limit the increasingly visible economical damage.
The Socialists want to raise taxes & give everything away for FREE. This badly damages the MORAL base on which society stands. On the other hand, the neo-Nazis of the extreme right are hardly a MORAL improvement.
Society cannot be held hostage by a continuous tit for tat gunfight between the extremes of left & right. I hold that the two-party system has passed its USE BY date.
At this time, we need to be developing a well-crafted CENTRIST party; one that can govern even-handedly. Then turn to these two extremes to declare A POX ON BOTH YOUR HOUSES.
Ken, I have a book in the Dutch language in which, during a fraught discussion between a sergeant and a private, the argument about socialists giving away everything is dealt with in the almost exact wording that you use. Sorry mate, it’s nonsense. The ones giving away millions to their buddies are the likes of Boris Johnson or Nigel Farage.
"The big difference is that the risk aversion is 500% higher. I’ve thought a lot about why that might be, and there are many factors, but I think one of the principal reasons is towards the end of the Conservative era the senior civil service came to believe that its job was to save the country from the government. Maybe that was a good thing, given it was chaos, but that’s left a legacy. So I see more and hear more ‘not sure about that, oh dear that will be quite difficult’.
I see this here in the US, at all levels, and not just in government. It might almost be the theme of the times. Those that have jobs - private or public - are desperate to keep them, and the rest live in a gig economy that's far from secure. Pushing for real change is a risky and uncertain business. Keeping one's head down therefore makes sense, while the alternative offers little payoff.
This was an interesting choice for an interview, Sam, and I was intrigued to read it. Whilst I would love to be a dispassionate observer on the areas covered by Alan Milburn, in this interview, I can’t be. I caught an infection in a London Hospital in 2007 (I was one of many who did at that time because infection control was a major problem) and I still have that infection now because it spread to my bones - I was lost to follow up (long story but largely as a result of New Labour’s reforms).
I take issue with Milburn almost immediately because he says ‘Oh, they’re not as good as we were’ that’s not true. He’s right in one sense, he was not very good and neither were several of his successors. He inherited an NHS in a much better, but still struggling, state than it is now but the decisions made by the last Labour govt are partly responsible for the mess it’s in now. PFI saddled the NHS with enormous debts and it took far too long for the last Labour govt to get hospital acquired infections under control. Moreover, the scandal of mixed wards continued well into the 2000’s and it was the coalition govt that finally claimed it had ended them.
I think most people agree that the Thatcherite status quo in this country has failed because creating monopolies run by private businesses who cream off huge sums of public money is doomed. The big failure of this current administration is that they promised change but have instead brought back people Milburn, and Mandelson, who didn’t do a good job the first time, to advise on continuing the status quo - but maybe in a slightly different way.
To touch on Milburn’s other area, he’s looking at welfare but that is another mess created by the last Labour govt. I think it was James Parnell who thought private firms could employ speech therapists and suchlike to decided on a sick person’s capability to work. Ian Duncan Smith just took this and made it far worse whilst continuing to enrich outsource companies. What unique skill does Milburn possess that will improve welfare in this country? He’s spent most of his career working for private healthcare companies.
I have nothing against the private sector as I worked in the private sector for my working life. However, when they carry out actions previously carried out by the state and do a much worse job but at huge expense I do object strongly. How can Streeting and Milburn think that throwing huge amounts of money at shareholder and directors is going to fix the NHS?
Thank you Sam and Alan. It does me good to hear a lot of common sense from a fellow Geordie. Ah, the "vision" thing and leadership developing a narrative that the people will follow! It would be nice to feel that the polycritical political context would allow even the present mediocrities running the place were capable of rising to the occasion. Alan, you seem to have greater faith in Wes Streeting's capacity to envision and embody such an approach. It would be interesting to hear more about him and what he has under his belt in the light of the current chaotic pre-electoral "Starmer is walking dead" crisis.
Interesting to read about the need for argument and coherence in vision, strategy and delivery. About 20 years ago I became involved in the programme to close many of the Remploy factories and transform the organisation into one that found work for those with disabilities in mainstream employers. Agree or disagree with the policy, there was a clear line of sight between the programme and a speech that Blair had made years earlier on Rights and Responsibilities, the overarching aim of which was to raise the percentage of people in employment. The equally controversial policy to move single parents from income support to Job Seekers Allowance was part of the same vision.
Alan’s ideas of system change are not ones you agree with Sam as you have stated this is likely not the best place to start as so many obstacles. I can see this having been a civil servant.
Alan is praying that the leadership capacity and more important capability will materialise to do this. I cannot see it , but i too pray it will emerge.
It could come through institutionalising a system wide system of incentives for encouraging improvement rather than checking vs lists as current inspectorates do.
The Audit Commission, before it became a best value inspectorate of checkers did this with some success.
Would really appreciate if you would release the actual audio of the interview as a podcast. Hearing it via AI-generated voice isn’t the same. ChinaTalk does this in reverse, I’m sure you can too!! Thanks for sharing.
Thanks. I can't in this instance because it was recorded in a noisy cafe so the audio is unlistenable! But it's a good nudge for future interviews. Part of the challenges is that I cut them down a lot to make them readable so the audio would be different from the published transcript so need to think about how that would work.
Thanks for responding. Totally get it.
For instance, ChinaTalk records the podcast first and then generates the transcript. Both available on Substack. It’s possible via RSS feed ID to make audio available to subscribers via Apple Podcasts. Or via the hideous Substack podcast player 🤣🤣
Yeah - I think the difference is they do there's as podcasts and the transcripts are a secondary resource whereas I do them to be written up. I've toyed with the idea of doing proper podcasts as part of the substack but I'm so attached to writing that I don't enjoy it nearly as much!
Totally get it. It’s a balancing act. Thanks for sharing!